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To utilize specialized clinical knowledge to support physicians and other health care providers to improve clinical documentation throughout the El Camino Hospital organization. Works collaboratively with medical, nursing and ancillary staffs and HIMS coders to improve the quality of chart documentation to assure appropriate DRG classification, ICD code capture, and accurately reflect patient severity and risk of mortality. Involved in projects that support the Hospital's enterprise-wide goals and objectives to improve clinical document management.
The Clinical Documentation Specialist facilitates clarification of clinical documentation through concurrent interaction with physicians and other members of the health care team to support the capture of appropriate clinical complexity for the level of service rendered to all inpatients.
The CDS will:
Provide daily clinical review of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans
Be responsible for the day-to-day review of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures and official coding guidelines.
Communicate with physicians, face to face or via clinical documentation query forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
Communicate with appropriate healthcare team members to ensure accurate, complete, and compliant documentation in the medical record
Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
Gather and analyze information pertinent to documentation findings and outcomes
1. Bachelor's degree in Nursing or graduate of a medical school with a medical doctorate degree from inside or outside the U.S
2. At least 5 years of acute clinical experience. Critical care background preferred.
3. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.
4. Minimum of 2 years of experience as a clinical documentation specialist.
5. CCS or Coding experience preferred.
6. Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching.
7. Knowledge of federal, state and private payer regulations.
1. Valid U.S. RN License OR Medical Doctorate
2. Required to obtain Certified Clinical Documentation Specialist (CCDS) Credential within 24 months of hire.
3. Current California state driver's license, valid insurance, and ability to travel between El Camino Hospital locations.